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Healthfirst Reimbursement Policy Updates: Allergy Studies, Allergen Immunotherapy and Diabetic Management Services

Healthfirst aims to ensure that reimbursement policy standards are up to date and are compliant with state and national industry standards. Healthfirst is updating reimbursement policies of Allergen Immunotherapy, Allergy Studies, and Diabetic Management Services starting March 1, 2020.


Professional Services for Allergen Immunotherapy
Not Including Provision of Allergenic Extracts

Policy Overview

Effective March 1, 2020, consistent with the policies of the American Academy of Allergy, Asthma, and Immunology, Healthfirst will no longer reimburse any combination of “professional services for allergen immunotherapy not including the provision of allergenic extracts” when billed with greater than three unique visits per week.

According to the American Academy of Allergy, Asthma, and Immunology, the frequency of allergen immunotherapy administration is generally 1 to 3 injections per week.

Billing Information

This policy applies to the following service codes:

  • 95115: Professional services for allergen immunotherapy, not including the provision of allergenic extracts; single injection.
  • 95117: Professional services for allergen immunotherapy, not including the provision of allergenic extracts, two or more injections.


Allergy Studies

Policy Overview

Effective March 1, 2020, consistent with CMS Local Coverage Determinations (jurisdiction N), Healthfirst will no longer reimburse allergy studies when billed with more than 100 units for a single patient within a one-year (365 days) time frame.

According to CMS, it would not be expected that:

  • More than twenty (20) units will be reported for percutaneous testing per year for food sensitivity.
  • More than forty (40) units will be reported for intracutaneous (intradermal) testing with allergenic extracts, immediate type reaction, per year for a patient.
  • More than forty (40) units will be reported for intracutaneous (intradermal), sequential and incremental testing with allergenic extracts for airborne allergens, immediate type reaction, per year for a patient.
  • All patients would receive the same tests or the same number of sensitivity tests.

The number of tests performed must be judicious and related to the history, physical findings, and clinical judgment specific to each individual patient.

Billing Information

This policy applies to the following service codes:

  • 95004: Percutaneous tests (scratch, puncture, or prick) with allergenic extracts, immediate type reaction, including test interpretation and report, specify number of tests.
  • 95017: Allergy testing, any combination of percutaneous (scratch, puncture, prick) and intracutaneous (intradermal), sequential and incremental, with venoms, immediate type reaction, including test interpretation and report, specify the number of tests.
  • 95018: Allergy testing, any combination of percutaneous (scratch, puncture, prick) and intracutaneous (intradermal), sequential and incremental, with drugs or biologicals, immediate type reaction, including test interpretation and report, specify the number of tests.
  • 95024: Intracutaneous (intradermal) tests with allergenic extracts, immediate type reaction, including test interpretation and report, specify the number of tests.
  • 95027: Intracutaneous (intradermal) tests, sequential and incremental, with allergenic extracts for airborne allergens, immediate type reaction, including test interpretation and report, specify number of tests

 

Diabetic Management Services

Policy Overview

Effective March 1, 2020, consistent with the HCPCS Level II Manual, Healthfirst will no longer reimburse Diabetic management program, dietitian visit, or Nutritional Counseling, dietitian visit when billed with a provider specialty that is not Nutritional Medicine, Diabetic Educator, or Hospital.

According to the HCPCS Level II Manual, a dietitian services visit will only be covered when performed by a registered dietitian, nutrition professional, certified diabetic educator, registered nurse certified diabetic educator (CDE) or in the hospital setting. These services should not be reported by any other provider specialty.

Billing Information

This policy applies to the following service codes:

  •  S9465: Diabetic management program, dietitian visit
  •  S9470: Nutritional counseling, dietitian visit

 

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Insights
February 2020